1
Addressed to: The Trust
Action Plan Published
Link to recommendation 1
Recommendation · source text
The Trust should further consider the opportunities and limitations of co-location across the patch for health and social care staff as a means to facilitate communication and information-sharing. Whilst co-location is not always possible or practical, the impact upon communication may be significant and extra care may be needed to develop solutions where co-location is impractical.
2
Addressed to: The Trust
Action Plan Published
Link to recommendation 2
Recommendation · source text
The investigation team recommends that attention is given as part of staff training and reflective practice to the association between mental ill health and caring for someone with significant mental and/or physical problems. New guidance on the value of an assessment of carers’ needs should be included as part of this.
3
Addressed to: The Trust
Action Plan Published
Link to recommendation 3
Recommendation · source text
It will be important for the Trust to include as a routine part of staff training and/or reflective practice a focus on the association between domestic violence and risk of homicide. This should help to ensure that policy on the conduct of initial interviews and risk assessment keeps pace with the evidence.
4
Addressed to: The Trust, and National and local commissioners of investigations
Action Plan Published
Link to recommendation 4
Recommendation · source text
The investigation team recommends that awareness is raised about the importance of family testimony. At local level for clinicians, this could be achieved via training for staff which includes representation from users, carers and family members as appropriate and/or a focus on reflective practice. We would also suggest that national and local commissioners of investigations (Stage 3 and Stage 2 respectively) strengthen their governance and quality assurance mechanisms for independent investigations to ensure that information from carers and families is always sought.
5
Addressed to: The Trust
Action Plan Published
Link to recommendation 5
Recommendation · source text
The investigation team believes that support for staff could be improved if, as a matter of course, a senior manager attended in person when a serious incident (SI) occurs. In addition, there may be value in developing a staff support policy to bring together all the guidance currently available on the intranet into one place. Responsibility to maintain and update this and ensure that support is tailored to individual needs to be clearly defined and assigned.